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J Reconstr Microsurg 2023; 39(03): 179-186
DOI: 10.1055/s-0042-1750127
Original Article

Planes for Perforator/Skin Flap Elevation—Definition, Classification, and Techniques

Jin Geun Kwon
1   Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
,
Erin Brown
2   Department of Plastic and Reconstructive Surgery, University of British Columbia, Vancouver, British Columbia
,
Hyunsuk Peter Suh
1   Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
,
Changsik John Pak
1   Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
,
Joon Pio Hong 
1   Department of Plastic Surgery, Asan Medical Center, University of Ulsan Collage of Medicine, Songpa-gu, Seoul, Republic of Korea
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Abstract

Background Elevation in different layers achieving thin flaps are becoming relatively common practice for perforator flaps. Although postreconstruction debulking achieves pleasing aesthetic results and is widely practiced, customized approach during elevation to achieve the ideal thickness will increase efficiency while achieving the best possible aesthetic outcome. Multiple planes for elevation have been reported along with different techniques but it is quite confusing and may lack correspondence to the innate anatomy of the skin and subcutaneous tissue.

Methods This article reviews the different planes of elevation and aims to clarify the definition and classification in accordance to anatomy and present the pros and cons of elevation based on the different layers and provide technical tips for elevation.

Results Five different planes of elevation for perforator flaps are identified: subfascial, suprafacial, superthin, ultrathin, and subdermal (pure skin) layers based on experience, literature, and anatomy.

Conclusion These planes all have their unique properties and challenges. Understanding the benefits and limits along with the technical aspect will allow the surgeon to better apply the perforator flaps.

Keywords

perforator flap - flap elevation planes - thin flaps - superthin flaps


Publication History

Received: 10 January 2022

Accepted: 23 April 2022

Article published online:
22 November 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93 (07) 1503-1504
    CrossrefPubMedGoogle Scholar
  • 2 Ross GL, Dunn R, Kirkpatrick J. et al. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg 2003; 56 (04) 409-413
    CrossrefPubMedGoogle Scholar
  • 3 Sharabi SE, Hatef DA, Koshy JC, Jain A, Cole PD, Hollier Jr LH. Is primary thinning of the anterolateral thigh flap recommended?. Ann Plast Surg 2010; 65 (06) 555-559
    CrossrefPubMedGoogle Scholar
  • 4 Kimura N. A microdissected thin tensor fasciae latae perforator flap. Plast Reconstr Surg 2002; 109 (01) 69-77 , discussion 78–80
    CrossrefPubMedGoogle Scholar
  • 5 Park BY. Flap thinning: Defatting after conventional elevation. Arch Plast Surg 2018; 45 (04) 314-318
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Hong JP, Choi DH, Suh H. et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014; 30 (07) 491-496
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Hong JP, Chung IW. The superficial fascia as a new plane of elevation for anterolateral thigh flaps. Ann Plast Surg 2013; 70 (02) 192-195
    CrossrefPubMedGoogle Scholar
  • 8 Hong JP, Yim JH, Malzone G, Lee KJ, Dashti T, Suh HS. The thin gluteal artery perforator free flap to resurface the posterior aspect of the leg and foot. Plast Reconstr Surg 2014; 133 (05) 1184-1191
    CrossrefPubMedGoogle Scholar
  • 9 Jeong HH, Hong JP, Suh HS. Thin elevation: a technique for achieving thin perforator flaps. Arch Plast Surg 2018; 45 (04) 304-313
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Sakarya AH, Do N. Nomenclature of thin and super-thin flaps-comment on: outcomes of subfascial, suprafascial, and super-thin anterolateral thigh flaps: tailoring thickness without added morbidity. J Reconstr Microsurg 2018; 34 (03) e3-e4
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Park SO, Chang H, Imanishi N. Anatomic basis for flap thinning. Arch Plast Surg 2018; 45 (04) 298-303
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Kim KN, Hong JP, Park CR, Yoon CS. Modification of the elevation plane and defatting technique to create a thin thoracodorsal artery perforator flap. J Reconstr Microsurg 2016; 32 (02) 142-146
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Narushima M, Yamasoba T, Iida T. et al. Pure skin perforator flaps: the anatomical vascularity of the superthin flap. Plast Reconstr Surg 2018; 142 (03) 351e-360e
    CrossrefPubMedGoogle Scholar
  • 14 Kimura N, Satoh K. Consideration of a thin flap as an entity and clinical applications of the thin anterolateral thigh flap. Plast Reconstr Surg 1996; 97 (05) 985-992
    CrossrefPubMedGoogle Scholar
  • 15 Visconti G, Bianchi A, Hayashi A, Salgarello M. Pure skin perforator flap direct elevation above the subdermal plane using preoperative ultra-high frequency ultrasound planning: a proof of concept. J Plast Reconstr Aesthet Surg 2019; 72 (10) 1700-1738
    CrossrefPubMedGoogle Scholar
  • 16 Bhadkamkar MA, Wolfswinkel EM, Hatef DA. et al. The ultra-thin, fascia-only anterolateral thigh flap. J Reconstr Microsurg 2014; 30 (09) 599-606
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Patel KM, Shauly O, Gould DJ. Introducing the subdermal free flap: preserving the ultrathin-free skin flap option in morbidly obese patients. J Surg Oncol 2018; 118 (03) 403-406
    CrossrefPubMedGoogle Scholar
  • 18 Yamamoto T, Yoshimatsu H, Kikuchi K. Free prepuce perforator flap: ultra-thin superficial penile artery perforator flap for a dorsal finger defect. Microsurgery 2017; 37 (03) 252-255
    CrossrefPubMedGoogle Scholar
  • 19 Kumar P, Pandey AK, Kumar B, Aithal SK. Anatomical study of superficial fascia and localized fat deposits of abdomen. Indian J Plast Surg 2011; 44 (03) 478-483
    CrossrefPubMedGoogle Scholar
  • 20 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124 (05) 1529-1544
    CrossrefPubMedGoogle Scholar
  • 21 Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator flaps: history, controversies, physiology, anatomy, and use in reconstruction. Plast Reconstr Surg 2009; 123 (04) 132e-145e
    CrossrefPubMedGoogle Scholar
  • 22 Kehrer A, Sachanadani NS, da Silva NPB. et al. Step-by-step guide to ultrasound-based design of alt flaps by the microsurgeon - basic and advanced applications and device settings. J Plast Reconstr Aesthet Surg 2020; 73 (06) 1081-1090
    CrossrefPubMedGoogle Scholar
  • 23 Goh TLH, Park SW, Cho JY, Choi JW, Hong JP. The search for the ideal thin skin flap: superficial circumflex iliac artery perforator flap–a review of 210 cases. Plast Reconstr Surg 2015; 135 (02) 592-601
    CrossrefPubMedGoogle Scholar
  • 24 Suh HSP, Jeong HH, Choi DH, Hong JPJP. Study of the medial superficial perforator of the superficial circumflex iliac artery perforator flap using computed tomographic angiography and surgical anatomy in 142 patients. Plast Reconstr Surg 2017; 139 (03) 738-748
    CrossrefPubMedGoogle Scholar
  • 25 Cho MJ, Kwon JG, Pak CJ, Suh HP, Hong JP. The role of duplex ultrasound in microsurgical reconstruction: review and technical considerations. J Reconstr Microsurg 2020; 36 (07) 514-521
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Chae MP, Hunter-Smith DJ, Rozen WM. Comparative analysis of fluorescent angiography, computed tomographic angiography and magnetic resonance angiography for planning autologous breast reconstruction. Gland Surg 2015; 4 (02) 164-178
    PubMedGoogle Scholar
  • 27 Katayama H, Yamaguchi K, Kozuka T, Takashima T, Seez P, Matsuura K. Adverse reactions to ionic and nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media. Radiology 1990; 175 (03) 621-628
    CrossrefPubMedGoogle Scholar
  • 28 Dillman JR, Ellis JH, Cohan RH, Strouse PJ, Jan SC. Frequency and severity of acute allergic-like reactions to gadolinium-containing i.v. contrast media in children and adults. AJR Am J Roentgenol 2007; 189 (06) 1533-1538
    CrossrefPubMedGoogle Scholar
  • 29 Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg 2008; 121 (01) 9-16
    PubMedGoogle Scholar
  • 30 Aubry S, Pauchot J, Kastler A, Laurent O, Tropet Y, Runge M. Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery. Skeletal Radiol 2013; 42 (03) 319-327
    CrossrefPubMedGoogle Scholar
  • 31 Solomon GA, Yaremchuk MJ, Manson PN. Doppler ultrasound surface monitoring of both arterial and venous flow in clinical free tissue transfers. J Reconstr Microsurg 1986; 3 (01) 39-41
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Visconti G, Bianchi A, Hayashi A. et al. Thin and superthin perforator flap elevation based on preoperative planning with ultrahigh-frequency ultrasound. Arch Plast Surg 2020; 47 (04) 365-370
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Visconti G, Bianchi A, Hayashi A, Salgarello M. Designing an anterolateral thigh flap using ultrasound. J Reconstr Microsurg 2022; 38 (03) 206-216
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Thiele JR, Weiß J, Braig D, Zeller J, Stark GB, Eisenhardt SU. Evaluation of the suprafascial thin ALT flap in foot and ankle reconstruction. J Reconstr Microsurg 2022; 38 (02) 151-159
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Blondeel PN, Beyens G, Verhaeghe R. et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg 1998; 51 (03) 202-209
    CrossrefPubMedGoogle Scholar
  • 36 Hallock GG. Evaluation of fasciocutaneous perforators using color duplex imaging. Plast Reconstr Surg 1994; 94 (05) 644-651
    CrossrefPubMedGoogle Scholar
  • 37 Wang LV, Hu S. Photoacoustic tomography: in vivo imaging from organelles to organs. Science 2012; 335 (6075): 1458-1462
    CrossrefPubMedGoogle Scholar
  • 38 Tsuge I, Saito S, Yamamoto G. et al. Preoperative vascular mapping for anterolateral thigh flap surgeries: a clinical trial of photoacoustic tomography imaging. Microsurgery 2020; 40 (03) 324-330
    CrossrefPubMedGoogle Scholar
  • 39 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40 (02) 113-141
    CrossrefPubMedGoogle Scholar
  • 40 Boyd JB. Discussion: qualitative and quantitative analyses of donor-site morbidity following suprafascial versus subfascial free fibula flap harvesting. Plast Reconstr Surg 2011; 128 (01) 146-147
    CrossrefPubMedGoogle Scholar
  • 41 Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004; 114 (04) 910-916
    CrossrefPubMedGoogle Scholar
  • 42 Wallace CG, Kao HK, Jeng SF, Wei FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg 2009; 124 (6, Suppl): e419-e426
    CrossrefPubMedGoogle Scholar
  • 43 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (07) 2219-2226 , discussion 2227–2230
    CrossrefPubMedGoogle Scholar
  • 44 Schaverien M, Saint-Cyr M. Suprafascial compared with subfascial harvest of the radial forearm flap: an anatomic study. J Hand Surg Am 2008; 33 (01) 97-101
    CrossrefPubMedGoogle Scholar
  • 45 Sagalongos OS, Valerio IL, Hsieh CH. et al. Qualitative and quantitative analyses of donor-site morbidity following suprafascial versus subfascial free fibula flap harvesting. Plast Reconstr Surg 2011; 128 (01) 137-145
    CrossrefPubMedGoogle Scholar
  • 46 Su XZ, Yin SC, So HI. et al. Comparison of donor site complications of supra- versus subfascially harvested anterolateral thigh perforator free flaps: a meta-analysis. J Craniomaxillofac Surg 2020; 48 (01) 56-66
    CrossrefPubMedGoogle Scholar
  • 47 Fischer S, Diehm Y, Hirche C. et al. Comparison of sub- versus suprafascially raised anterolateral thigh free flaps with regard to donor-site morbidity, function and aesthetics. Microsurgery 2018; 38 (05) 444-449
    CrossrefPubMedGoogle Scholar
  • 48 Avery CM, Sundaram K, Jasani V, Peden A, Neal CP. Comparison of sensory recovery at the subfascial and suprafascial donor sites of the free radial flap. Br J Oral Maxillofac Surg 2012; 50 (06) 495-499
    CrossrefPubMedGoogle Scholar
  • 49 Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg 2010; 125 (03) 924-934
    CrossrefPubMedGoogle Scholar
  • 50 Lee KT, Park SJ, Mun GH. Reconstruction outcomes of oncologic foot defect using well-contoured free perforator flaps. Ann Surg Oncol 2017; 24 (08) 2404-2412
    CrossrefPubMedGoogle Scholar
  • 51 Alkureishi LW, Shaw-Dunn J, Ross GL. Effects of thinning the anterolateral thigh flap on the blood supply to the skin. Br J Plast Surg 2003; 56 (04) 401-408
    CrossrefPubMedGoogle Scholar
  • 52 Chen YC, Scaglioni MF, Carrillo Jimenez LE, Yang JC, Huang EY, Lin TS. Suprafascial anterolateral thigh flap harvest: a better way to minimize donor-site morbidity in head and neck reconstruction. Plast Reconstr Surg 2016; 138 (03) 689-698
    CrossrefPubMedGoogle Scholar
  • 53 Suh YC, Kim NR, Jun DW, Lee JH, Kim YJ. The perforator-centralizing technique for super-thin anterolateral thigh perforator flaps: minimizing the partial necrosis rate. Arch Plast Surg 2021; 48 (01) 121-126
    Article in Thieme ConnectPubMedGoogle Scholar
  • 54 Kimura N, Satoh K, Hosaka Y. Microdissected thin perforator flaps: 46 cases. Plast Reconstr Surg 2003; 112 (07) 1875-1885
    CrossrefPubMedGoogle Scholar
  • 55 Narushima M, Yamasoba T, Iida T. et al. Pure skin perforator flap for microtia and congenital aural atresia using supermicrosurgical techniques. J Plast Reconstr Aesthet Surg 2011; 64 (12) 1580-1584
    CrossrefPubMedGoogle Scholar
  • 56 Imanishi N, Nakajima H, Minabe T, Aiso S. Angiographic study of the subdermal plexus: a preliminary report. Scand J Plast Reconstr Surg Hand Surg 2000; 34 (02) 113-116
    CrossrefPubMedGoogle Scholar
  • 57 Narushima M, Yamasoba T, Iida T. et al. Supermicrosurgical reconstruction for congenital aural atresia using a pure skin perforator flap: concept and long-term results. Plast Reconstr Surg 2013; 131 (06) 1359-1366
    CrossrefPubMedGoogle Scholar
  • 58 Hong JP, Suh HP. Discussion: pure skin perforator flaps: the anatomical vascularity of the superthin flap. Plast Reconstr Surg 2018; 142 (03) 361e-362e
    CrossrefPubMedGoogle Scholar